Welcome!
Please fill out each question thoroughly. You may save your answers in a separate document.
What is your name?
First Name
Last Name
What is your birth date?
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Year
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Month
Day
Date
Where were you born (city and state) and what time were you born (be as exact as possible)
This is for Human Design information; if you are not interested then you may leave blank.
Are you male or female?
Male
Female
What city and state do you live in now?
Describe your community. Who do you live with? Are you single, married, and do you have any children? Who do you surround yourself with?
Is your community supportive of your journey?
What situations; peer pressure, work environment, stress levels, busy days, etc. do you find as a challenge, barrier, or interruption to your health journey?
Why are you here?
Please list your top 3-5 areas of focus (you may also select all!)
Weight loss / Management
Gut Help
Hormone Balancing
Auto-immune or Disease Management
Muscle Building / Tailored Programming
Nutrition Education
Spiritual or Energetic Systems
Reducing Medication Use
Sleep and/or Nervous System Regulation
Behavioral & Disordered Eating (ie, binging, OCD calorie/macro counting, etc)
Overall Lifestyle Management
Other
Please elaborate on your selections by providing specific information or details as they pertain to your situation and goals.
How long do you anticipate working with Body Alchemy LLC
3 Months
3 - 6 Months
6 months or more
It takes as long as it takes!
What is your body's current state of health?
Please be thorough in your responses. Be sure to save your answers in separate document.
What is your current weight?
What is your height?
If you have a DEXA, InBody, or body compositions results, please upload here
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Please upload or email any lab-work from within the last year.
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Email: bodyalchemy@bodyalchemynutrition.com
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Recent, Chronic or Past Diagnosis
Hashimoto's or Thyroid Disorder
Celiac Disease
PCOS
Type 1 or Type 2 Diabetes
Metabolic Syndrome/Insulin Resistance
IBS/IBD/SIBO
GERD/Acid Reflux
Chronic fatigue / fibromyalgia
Lupus or another autoimmune disease
Anxiety / Depression
ADD or ADHD
Infertility
Mold / Lyme / EBV
Heavy metal toxicity
Chronic viral or bacterial infections
Cancer - please specify
Other
Please include any other illness, medical diagnosis, injuries, or surgeries you've had in the past.
How often do you get sick each year? Are your prone to catching colds or the flu?
Do you have environmental allergies, runny nose, watery/itchy eyes?
Do you experience fatigue, brain fog, sluggishness? If so, how often through out the day?
Please list all medications you are currently on, or have used in the past for durations longer than 30 days (this includes antibiotics). Why are you or were you taking these?
Please list all supplements you take consistently, or have used in the past for durations longer than 30 days. Why are you or were you taking these?
Did you receive COVID-19 vaccines or boosters?
Please list ANY family history (both immediate and extended) of health problems; mental health, disease, weight issues, etc, and the family member’s relation to you:
Do you experience indigestion, constipation, bloating, and/or diarrhea? If so, how often?
Answer Here
Do you have any food sensitivities or digestive issues?
Please describe your sleep quality by providing information regarding what time you go to bed and wake up, if you have trouble falling or staying asleep, and if you feel rested upon waking.
Please describe your energy quality by providing information regarding your daily schedule and activities, when you feel rested, and when you feel stressed.
If female, are you currently menstruating? Please list cycle dates.
Are your cycles regular? Painful? Emotionally difficult?
Have you used hormonal birth control? How long? What kind(s)
Are you perimenopausal or postmenopausal.
If male, have you experienced signs of low testosterone such as low libido, mood shifts, weight gain, muscle atrophy?
Have you had your T levels tested? Please provide when levels at the time of testing.
Are you on or considering TRT?
Please list your current physical activity level and type of activities on a day to day and weekly basis. Please also note how many hours you are seated / sedentary.
Early and Past Development History
Were you breastfed or formula fed as baby? If breastfed, for how long?
Were you born via vaginal delivery or C-section?
Were you sick often as a child?
Were you frequently on antibiotics as a child?
Were you prescribed any other medications in adolescence or early adulthood?
Nutrition and Exercise Assessment
Did you play sports (or highly active) growing up? Which ones?
What forms of exercise do you enjoy or that you responded to in the past?
Did you ever have any formal weight lifting training? For how long?
Have you worked with a nutritionist, dietitian, naturopath, functional provider, or coach in the past? Please provide a further explanation.
What is your history with "diets", detoxes, gut protocols, or any other method of healing or weight loss? Please list all diets or food plans you have tried.
What worked? What didn't? What had lasting value for you?
Please describe your current relationship to food and to alcohol.
Have you ever used an app to track calories or macronutrients? Which app did you use?
How often do you read nutrition labels?
What are your favorite foods to eat? What food are you adversed to?
How much water do you drink daily? What is the source?
Integrity Contract
We begin building integrity in the body when we build integrity in character.
Please write a letter of commitment to your self, followed by your inspiration to take ownership of your health and body in order to reach your goals.
Do you 100% agree that you are always in choice and in charge of your reactions and behaviors at all times?
Are you willing to accept full responsibility and free will to make these changes in your life?
Terms & Conditions
*
Please sign your name
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